Personal data Patient’s name :M.S

Gender : Male

Date of Birth: 20th Mar 2003

Age: 14 years

Nationality: Jordanian

Medical & Dental HistoryMedical History:

denied any medical problems .

Dental History:

Previous visits to dental clinic for check-ups

previous root canal treatment in upper right first molar before a year .

Habits: No habits noticed or mentioned

Motivation: Highly motivated.

Expectations: High expectations.

Chief Complaint

“I don’t like the appearance of my upper anterior teeth.

They are too prominent .

Jaw & Occlusal Function

Mastication: Normal masticatory pattern.

Speech:

Normal flow of speech.

No difficulties detected

TMJ:

No signs of TMJ dysfunction (No clicking,

no crepitus, no tenderness to palpation)

Good range of opening

Good range of lateral movement

Extra-Oral Photosa)frontal view

B)profile view

c) oblique view

Extra-Oral examination A)Skeletal assessment:

Anteroposterior assessment:

• Class II Skeletal pattern

A)Skeletal assessment

Transverse assessment :

• Symmetrical face

A)Skeletal assessmentVertical assessment :

• Average LFH .

Soft Tissue Examination

Asymmetrical face.

Interpupillary distance larger than the width of the mouth.

Larger Right side than Left side.

Soft Tissue Examination

• Convex profile.

• Incompetent lips.

Soft Tissue Examination• Frontonasal angle:

133˚ (Normal 115⁰-135⁰) • Nasolabial angle:

96˚ (Normal 90⁰-110⁰)• Labio-mental angle ‘’Acute ‘’

106˚ (Normal 114⁰-140)• Chin throat angle: “obtuse ‘’

128˚ ( Normal close to 90)

Intra-oral photos

Intra-oral Examination: • Teeth present

7654321 1234567 7654321 1234567

• Fair oral hygiene.• Generalized fluorosis.• Gingival inflamed and swollen in both U&L ant. Region.

Lower Arch:A. U shape arch.

B. Anterior segment:

well aligned teeth.

C. Posterior segment:

rotated R&L 2nd premolars.

carious teeth

765 46

Upper Arch:

A. U shape ArchB. Anterior segment: slight proclined upper incisors. slight displaced palatally UR2.C. Posterior segment: rotated UR&L 1st premolars. broken restoration UR 1st molar. carious teeth:

7 4 67

Anterior segment

• Class II/1 incisor relationship.• Midline is not coincident.• Upper midline shift to the right side

1mm.• Lower midline shift to the right side

2mm.• Overjet: 7mm.• Overbite: incomplete deep bite 70%.

Buccal segment Molar relationship : class II ½ unit in Rt & Lt sides.

Canine relationship : class II ½ unit in Rt& Lt sides.

Molar relation : CII ½

Canine relation : CII ½

No crossbite .

Molar relation : CII ½

Canine relation : CII ½

No crossbite .

• lower incisor edges are palatal to the cingulum plateau of the upper incisors .

• Incomplete deep overbite .

• U shape arch .

• Inter canine width (3—3 ) = 27 mm.

• Intermolar width (6—6) = 45 mm.

27mm

45 mm

• U shape Arch.

• Inter canine width (3 – 3) = 34 mm

• Inter molar width (6 – 6) = 49 mm

34 mm

Rt Lt3mm

Smile analysis

I) Lip line :

Average

Accepted

II) Smile arc :

curvature of maxillary incisal edge parallel with the curvature of the lower lipsmile arc— “consonant”

III) Upper lip curvature :

Upward upper lip curvature

IV) Lateral negative space

Wide buccal corridor on smiling

NotAccepted

V) Smile symmetry

symmetrical smile

VI) Frontal Occlusal Plane

canted occlusal frontal plane

NotAccepted

VII) Dental component

• Upper dental midline is not coincide with facial midline.

• Crown angulation parallelism is not coincident .

VIII)Gingival contour

• Gingival margin of upper Rt canine is higher than central incisors .

• Gingival margin of upper Rt lateral incisor is more near to the level of upper central incisor .

NotAccepted

Space analysis Lower arch:

space available = 71 space required = 71

No crowding

Upper arch :space available =83

space required=80(+3 ) = spacing

LowerUpper

0mm+3mmCrowding and spacing

-2mm0mmLeveling of oclusal curve

0-10mmIncisors AP position

-2mm-7mmTotal

Royal London Space Analysis

Bolton Ratio There is increased in the lower anterior teeth.

)(%83

%10048

40

%100)33(

)33(

inceased

Max

MandRatioBoltonAnterior

)(%5.85

%10083

71

%100)66(

)66(

reduced

Max

MandRatioBoltonOverall

Index Of Orthodontic Treatment Need (IONT)

Figure 1

Index Of Orthodontic Treatment Need (IOTN)

• Grade 4

4a. Increase overjet > 6mm but < 9mm.

-All teeth are present including 3rd molars.-Condyles are in normal shape and position.-Normal Maxillary sinuses.-No bony pathology.-RCT on UR 6.

Cervical Vertebral Maturation

CS4 :Peak of mandibular growth has occurred within 1 or 2 yrs.' before this stage .25% - 10% remaining.

Cephalometric AnalysisnormalPre-

treatment variable

81 +/-378.5SNA

78 +/-373SNB

3 +/-15.5ANB

8+/- 36.8Sn/Mx

7Corrected ANB

0mmmmWits appraisal

27+/- 424FMPA

109 +/-6116UI/Mx plane

93 +/-699LI/Mand plane

133 +/-10Interincisalangle

27 +/-426MM angle

62mmUpper AFH

77mmLower AFH

55+/_255%Lower Faceheight ratio

59-63%63%Jaraback ratio

Diagnostic summaryA 13 years old male, denied any medical problem, presented with concern

about the appearance of his upper front teeth are too prominent. he had fair oral hygiene, multiple carious teeth, gingival inflammation in both U&L ant. teeth, generalized fluorosis and broken filling with RCT on UR6.

He exhibited a class II div I incisors malocclusion on class II skeletal base, with convex profile, average lower face height, incompetent lips and wide buccal corridors.

Dentally, he has increased overjet 7mm ,incomplete deep overbite 70% ,well aligned lower arch, spaced upper arch 3mm with slightly proclined upper & lower incisors, slightly displaced UR2, rotated UR&L 1st premolars & LR&L 2nd premolars, U&L midline shift to the right side, both molars & canines are classII ½ unit relationship, increased Bolton ratio and curve of spee of 3mm.

Problem list Pathological problems:

• Fair O.H. • Generalized fluorosis.• Multiple carious teeth.• Gingival inflammation of U & L ant. region.• Broken restoration on UR6.

Patient’s concern:My upper anterior teeth are too prominent.

Skeletal problems:• Class II skeletal base.

{ Retro gnathic mandible }

Soft tissue problems:• Incompetent lips.• Convex profile.• Asymmetrical face.• Nose deviation to right side.

Dental problems:• Increased overjet 7mm.• Incomplete deep overbite 70%.• Slightly proclined upper incisors

and displaced UR2.• proclined lower incisors .• Rotated U R&L1st premolars and

L R&L2nd premolars.• Both midlines are shift to the

right side.• Class II/I incisor relationship.• Both molars and canines have

classII ½ unit relationship.• Increased anterior Bolton ratio.• Increased curve of spee 3mm.

Treatment Aims Improve oral hygiene. Restore carious teeth and broken restoration on UR6. Give the patient the desired appearance. Enhance forward growth of the mandible to improve facial profile and

mandible/cranial base relationship. Improve lip competency.Accept other soft tissue problems. Reduce overjet and overbite. Correction of upper & lower incisors inclination .Achieve class I molar and canine relationship. Achieve class I incisor relationship. Correction of rotated teeth. Correction the midline. Correction of anterior Bolton discrepancy. Correction of curve of spee.

Treatment plan:- “ Non Extraction Case” O. H. I .

Refer to perio. Clinic.

Refer to cons. Clinic .

1st phase :-

Functional appliance “ Twin Block appliance” .

2nd phase :-

Upper & Lower Fixed Appliance

“ Pre-adjusted edgewise Roth prescription slot 0.022”

Stripping in the lower anterior teeth.

Retention:-

o Lower fixed retainer.

o Conventional upper and lower Hawley Retainer.

Justification:-I. Refer to perio clinic for management of gingival inflammation .II. Refer to cons clinic to restore multiple carious teeth and broken restoration in UR6.

III. Growth modification appliance treatment : Growing patient. motivated patient. uncrowded, well aligned teeth . Dentally Cl ll/1 on mild Skeletal Cl II base due to deficient mandible (low SNB). Good vertical facial proportions.

Twin Block appliance: Esthetics and comfort & Full time wear because the twin block appliances are not bulky. Modification in Twin block design : incorporated with expansion screw to maintain normal transverse relation . incorporated with lower incisor capping to prevent more proclination in the lower

anterior teeth.Full time wearing the appliance Revaluate the case every 3 months with cephalometric superimposition to evaluate

the progress . At the end of first phase of treatment a simple upper appliance with an anterior

inclined plane was given to be worn full time for 3 - 6 months to maintain the skeletal corrections.

IV. Non-extraction :

growing patient .

No crowding in the upper and lower arch's.

space will be provided from stripping and de-rotation of rotated teeth

V. Fixed appliance using Roth prescription:

For 3D tooth movement , and average torque needed .

correction of midline “ either by stripping Or deferential elastics ’’

Derotation of rotated teeth .

Correction of anterior Bolton discrepancy .

Improve the smile aesthetics “reduce the wide buccal corridor by arch wire expansion , extrusion of UR3 for gingival contour correction’’.

Final finishing detailing .

VI. Retention :

• Long term : lower anterior fixed retainer:

For more stability of lower incisors .

• Short term: upper and lower Hawley retainer :

Upper and Lower Hawley 6month full time wear and 6 month night time .

For more settling and stability of overjet and overbite.

Thank You